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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 5401 best Purviance St., 1751 North Front St. CENSUS TRACT <br /> Owner's Name Poggio Bros. Phone <br /> Address 5268 N. Duncan Rd. TInden Cslif.`h95236 City <br /> Contractor's Name Purviance Drillers,P.C.Bow 64,Tj den,Galif. License # 240107 Phone .T <br /> 95236 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN � RECONDITION /x/ DESTRUCTION /_ <br /> PUMP INSTALLATION / j PUMP REPAIR/ / PUMP REPLACEMENT J7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK i mile SEWER LINES PIT PRIVY (J <br /> SEWAGE DISPOSAL FIELD j ffii7.e CESSPOOL/SEEPAGE PIT OTHER I <br /> , . PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL NJ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Z Cable Tool Dia. of Well Excavation ExistxW I2" w/1G1, TAM <br /> Domestic/private Drilled, Dia, of Well Casing to Instpkij $0 y.iner <br /> Domestic/public `Driven Gauge of Casing <br /> Z Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodio,Protection Rotary Type of Grout <br /> Disposal": Other Other Information <br /> Geophysical. � � Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: . /_/ State Work Done Install custoner HP Tur int <br /> PUMP -REPAIR: / / State Work Done , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING MDA77INAL IN PECTION. <br /> SIGNED TITLE Owner <br /> DRAW Pfft PLAN ON REVERSE SIDE) <br /> FOR DEPART NT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY :-w --«�-� DATE <br /> ADDITIONAL COMMENTS: s <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />